Focus on Phenobarbital: Applications for Alcohol and Sedative-Hypnotic Withdrawal

Prior to the onset of the COVID-19 pandemic, 14.5 million adults had an alcohol use disorder, and the risk of alcohol withdrawal in all hospitalized patients was approximately 8%. Now, over a year into the pandemic, more patients are using alcohol in a concerning manner and emergency department visits related to complications from alcohol use are increasing. Additionally, there are growing concerns about increased benzodiazepine use, GABAergic agents such as gabapentin, and novel sedatives such as phenibut, which especially is worrisome in the setting of strained healthcare resources and limited access to addiction treatment. Such agents are readily available for purchase online, and patients may present during withdrawal. Additional challenges arise when patients use a combination of sedative-hypnotic agents, with or without alcohol. In such cases, hospitalizations often require higher levels of care and complex withdrawal management. In the setting of limited healthcare resources, are there regimens that afford a safer and/or faster detoxification period from these substances?In recent years, phenobarbital has re-emerged as a favorable treatment option for both alcohol and sedative-hypnotic withdrawal. Several questions have emerged as its use has increased: What is the utility of phenobarbital monotherapy rather than a benzodiazepine-forward strategy for the management of withdrawal? Should phenobarbital only be used in combination with benzodiazepines and other agents? Should phenobarbital be used in the ambulatory setting, or only in acute care settings? When using phenobarbital for alcohol withdrawal, can patients be safely managed with a short hospitalization followed by a supervised outpatient phenobarbital taper? Are the patient characteristics that favor this type of management strategy? Can patients be discharged from the emergency department if their withdrawal is controlled after receiving phenobarbital? What adjunctive agents are useful alongside or after the use of phenobarbital for withdrawal and dependence? In this workshop we describe how the pathophysiology and resultant clinical presentation of alcohol and sedative-hypnotic withdrawal informs the rationale behind the use of phenobarbital-based treatment protocols for withdrawal. We will review the pharmacology of phenobarbital as it pertains to withdrawal management, and discuss the evidence base for the efficacy and safety of the various management strategies and compare this to standard benzodiazepine-based protocols.Instruction will be through an interactive case-based format with expert medical toxicology and addiction medicine faculty describing different approaches and highlighting key points throughout the case discussion. Examples of cases include: a patient with alcohol withdrawal-related delirium who has received 200mg diazepam in the past 24 hours; a patient who is trying to cut down on alcohol use but there are no inpatient hospital or detoxification beds available; a patient with a history of using variety of different sedatives who is currently using phenibut and would like to stop; and, a patient with a history of seizures who is using non-prescribed gabapentin and etizolam and would like to discontinue use.